Continuous Positive Airway Pressure Versus Oxygen Therapy in the Cardiac Surgical Ward: A Randomized Trial.

BACKGROUND: Noninvasive ventilation (NIV) is a common technique to manage patients with acute respiratory failure in the intensive care unit. However, use of NIV in general wards is less well described. The authors' aim was to demonstrate efficacy of NIV, applied in a cardiac surgery ward, in improving oxygenation in patients who developed hypoxemic acute respiratory failure after being discharged from the intensive care unit. DESIGN: Randomized, open-label trial. SETTING: University hospital. PARTICIPANTS: Sixty-four patients with hypoxemia (PaO2/FIO2 ratio between 100 and 250) admitted to the main ward after cardiac surgery. INTERVENTIONS: Patients were randomized to receive standard treatment (oxygen, early mobilization, a program of breathing exercises and diuretics) or continuous positive airway pressure in addition to standard treatment. Continuous positive airway pressure was administered 3 times a day for 2 consecutive days. Every cycle lasted 1 to 3 hours. All patients completed their 1-year follow-up. Data were analyzed according to the intention-to-treat principle. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the number of patients with PaO2/FIO2<200 48 hours after randomization. Continuous positive airway pressure use was associated with a statistically significant reduction in the number of patients with PaO2/FIO2<200 (4/33 [12%] v 14/31 [45%], p = 0.003). One patient in the control group died at the 30-day follow-up. CONCLUSIONS: Among patients with acute respiratory failure following cardiac surgery, administration of continuous positive airway pressure in the main ward was associated with improved respiratory outcome. This was the first study that was performed in the main ward of post-surgical patients with acute respiratory failure.

Long-term results of tricuspid annuloplasty with 3-dimensional-shaped rings: effective and durable!

OBJECTIVES: 3-Dimensional (3D)-shaped rings are largely adopted for tricuspid annuloplasty, but evidence about their long-term results is scanty. The goal of this study was to analyse the long-term results of tricuspid annuloplasty with 3D-shaped rings. MATERIALS AND METHODS: A retrospective review of our prospectively maintained database was carried out to identify all patients who underwent tricuspid valve repair with 3D-shaped rings between January 2011 and December 2014. Kaplan-Meier methods were used to analyse long-term survival. Cumulative incidence function using death as the competitive outcome was used to estimate cardiac death. RESULTS: A total of 168 patients were identified. The median age was 66 years. Eighty-two patients (49%) were in advanced New York Heart Association functional class III-IV. Atrial fibrillation (AF) was present in 101 (60%); the median ejection fraction was 60%. In 82 (49%) patients, a Medtronic 3D Contour annuloplasty ring was employed; in the remaining 86 (51%) patients, an Edwards MC3 ring was used. Cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 1.9 ± 1.1%, 95% confidence interval (CI) (0.51-4.95) at 7 years. The cumulative incidence function of recurrence of tricuspid regurgitation (TR) ≥2+ at 7 years was 14 ± 3.17%, 95% CI (8.49-20.82). Recurrence of TR ≥2+ at 7 years was not significantly different between the Medtronic 3D Contour and the Edwards MC3 rings (P = 0.3). AF was identified as the only independent predictor of recurrence of TR ≥2+. CONCLUSIONS: 3D-shaped rings are effective and durable. TR recurrence was relatively low at 7 years and usually moderate (2+/4+) without a significant difference between the 2 types of rings. The role of AF as a predictor of TR recurrence was confirmed.

Re-repair after previous mitral valve reconstruction: handle with care!

OBJECTIVES: Patients with recurrent mitral regurgitation after surgical repair are currently treated with a re-repair procedure or valve replacement. The aim of this study was to compare outcomes of our series of patients who underwent re-repair versus replacement in this setting. METHODS: From 2003 to 2017, a total of 79 patients with recurrent mitral regurgitation underwent re-repair, group A (39), or replacement, group B (40). Mean follow-up was 7.4 ± 3.27 years (max 14.4). Inverse Probability of Treatment Weighting was used to create comparable distributions of the covariates; the Kaplan-Meier method was used for survival and competing risk analysis for time to cardiac death, time to recurrence of MR ≥3+ and MR ≥2+. RESULTS: A re-repair was possible in 49.4% of patients (39/79). At hospital discharge, residual MR ≥2+ was present in 5 patients in group A, and none in group B (P < 0.001). The paired overall survival at 8 years was 100% in the re-repair group and 96.5 ± 2.34% in the replacement group (P = 0.069). The cumulative incidence function of cardiac death, with non-cardiac death as competitive event, at 8 years was 0% in group A and 3.5 ± 2.34% in group B (P = 0.077). The cumulative incidence function of MR ≥3+ at 8 years was 29.2 ± 8.81% in group A and 0% in group B (P < 0.001). CONCLUSIONS: Recurrent significant mitral regurgitation after re-repair is not rare already at 8 years, but the survival tends to be worse after replacement. This finding calls for a very selective approach in pursuing a re-repair only when the intraoperative findings and the immediate results are very reassuring as far as long-term durability is concerned.

Complete left atrial ablation with bipolar radiofrequency.

OBJECTIVE: Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device. METHODS: An innovative complete left atrial lesion set was performed using only bipolar radiofrequency in 70 consecutive patients (study group). In 67/70 patients (96%) mitral valve disease was the main indication to surgery. Atrial fibrillation was permanent in 42 patients (60%), persistent in 25 (36%) and paroxysmal in three patients (4%). After beating-heart pulmonary vein isolation on-pump, the coronary-free area of the AV groove was marked epicardially by sticking a needle into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus was then identified through the atriotomy and an endo-epicardial ablation was performed with the bipolar device involving the atrial wall, the coronary sinus, up to the annulus. The lesion set was then completed by connecting the encirclings and the left appendage, which was then sutured. Follow-up was 100% complete. Results were compared with those of a control group of 33 patients receiving bipolar radiofrequency left atrial ablations and a mitral connecting line with a second unipolar device. RESULTS: All patients survived. No major complication occurred. Haematoma of the AV groove was observed during retrograde cardioplegia in one case. No myocardial ischaemia or re-exploration for bleeding (median 325 cc, interquartile range 250-442) occurred. Two out of 70 patients required a permanent pacemaker for AV block. Freedom from atrial fibrillation was 84% (95% CI: 75%, 93%) at 6 months and 81% (95% CI: 70%, 93%) at 1 year. One patient had left flutter. Comparison with the control group did not show any difference in clinical outcomes, but revealed bipolar ablation to the mitral annulus to abate the per patient cost of the ablation devices (1245+/-50 euro vs 2403+/-17 euro; p<0.0001). CONCLUSIONS: Performing the mitral line with bipolar radiofrequency is safe and cost-effective. A complete left atrial ablation with a single bipolar radiofrequency device yields excellent clinical mid-term results.

Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy†.

OBJECTIVES: Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. METHODS: Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. RESULTS: Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6-year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. CONCLUSIONS: Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control.

Electrophysiological findings and long-term outcomes of percutaneous ablation of atrial arrhythmias after surgical ablation for atrial fibrillation†.

OBJECTIVES: Percutaneous ablation (PA) for relapsing atrial tachyarrhythmias after surgical ablation is an emerging therapy. The aim of this study is to report the electrophysiological findings and the procedural long-term outcomes of reablation, in this particular clinical setting. METHODS: We retrospectively analysed all patients who were readmitted to our centre for relapsing atrial arrhythmias after surgical ablation for atrial fibrillation (AF). RESULTS: From 2000 to 2011, 36 patients with previous surgical ablation of AF received additional percutaneous management. Seven patients had had biatrial Maze, 18 left atrial ablation lesion set and 11 pulmonary vein isolation. Energy sources involved were unipolar radiofrequency (RF) (n = 13), bipolar RF (n = 19), combined bipolar RF and cryoenergy (n = 2), cryoenergy (n = 1) and high intensity focused ultrasound (n = 1). The median time to reablation was 34 months (interquartile range: 10-66). The relapsing arrhythmias were left atrial tachycardia (n = 17), AF (n = 15), right atrial flutter (n = 2), right atrial tachycardia (n = 1) and biatrial atrial tachycardia (n = 1). Origin of re-entrant circuits was perimitral (n = 27), around pulmonary veins (PV) including posterior left atrium (n = 15) and cavotricuspid isthmus (n = 3). Twenty-seven (75%) patients had left isthmus catheter ablation and 11 (30%) reablation of PV. Eighteen out of the 27 perimitral circuits were in patients with previous left-atrial Maze; in 17 patients the mitral line was performed with bipolar RF only, without the addition of cryoenergy. The importance of an appropriate energy source is also underlined by the prevalence of gaps in PV isolation that occurred for two-thirds of patients treated using unipolar RF only, which has been discontinued since 2001. Ten patients (27%) needed more than 1 PA for relapsing arrhythmia. At the last follow-up of 97 ± 42 months, freedom from arrhythmias was 53% after single PAs and 67% after more than one procedure. No morbidity, mortality or strokes were recorded during the follow-up. CONCLUSIONS: Percutaneous treatment of highly symptomatic patients with unsuccessful previous surgical ablation is feasible, and relatively effective at the late follow-up. A multidisciplinary approach significantly improves the outcomes in these challenging patients.

Myocyte changes and their left atrial distribution in patients with chronic atrial fibrillation related to mitral valve disease.

It has been found that the pulmonary veins and adjacent left atrial posterior wall (LAPW) are deeply involved in both the initiation and maintenance of atrial fibrillation (AF), and the identification of these high-risk sites has aroused great interest in investigating their histopathologic substrate. We used light and conventional electron microscopy to evaluate the differential myocyte and interstitial changes in LAPW and left atrial appendage (LAA) samples from 28 patients with chronic AF undergoing mitral valve surgery and from 12 autoptic controls. There were always more myocytes with loss of sarcomeres in the LAPW than in the LAA (19.9% +/- 7.7% versus 8.2% +/- 5.0%; P < .0001), and the LAPW showed more marked immunohistochemical evidence of dedifferentiation, characterized by the reexpression of smooth muscle actin. In pathological left atria, myocyte diameter in the LAPW and LAA was comparable (19.0 +/- 1.5 versus 18.5 +/- 2.0 microm; not significant) but larger than in the controls (11.9 +/- 0.8 and 12.1 +/- 1.3 microm, respectively; P < .0001). A terminal deoxynucleotidyltransferase assay did not reveal any myocyte apoptosis. The LAPW also showed more interstitial fibrosis than the LAA (7.49% +/- 3.34% versus 2.80% +/- 1.35%; P < .0001). Ultrastructural examination confirmed the presence of myocyte myocytolysis in the perinuclear area and showed changes in mitochondrial shape. In conclusion, the LAPW in patients with chronic AF related to mitral valve disease seems to be a particular anatomical site in which major myocyte and interstitial changes are concentrated, whereas the LAA is more protected. This remodeling may increase the heterogeneity of LAPW electrical conduction, thus confirming this location as an elective target for the ablation treatment of AF.

Surgical ablation of atrial fibrillation with a novel bipolar radiofrequency device.

OBJECTIVE: When used for epicardial ablation, unipolar devices do not predictably yield transmural scars. Bipolar radiofrequency proved highly effective on the animal model, but clinical experience is still initial. We describe acute electrophysiologic findings and follow-up results of epicardial ablation with a novel bipolar radiofrequency device. METHODS: A bipolar ablator was used to perform a simplified left atrial lesion set in 90 consecutive patients with atrial fibrillation undergoing open heart surgery. Pacing thresholds were assessed during surgery to validate 24 pulmonary vein encircling lines (12 patients). Follow-up was 100% complete. RESULTS: In 67 of 90 patients (84%), mitral valve disease was the main indication to surgery. Atrial fibrillation was continuous in 74 patients (82%) and intermittent in 16 patients (18%). Pacing threshold assessment showed a complete conduction block in 22 of 24 pulmonary vein couples (92%) after a single ablation and in all patients after doubling of the encircling lines. No complications related to the ablation procedure were recorded. The sinus rhythm restoration rate was 79% at 3 months, 87% at 6 months, and 89% (17/18 patients) at 1 year. Postablation organized arrhythmias consisted in right atrial flutter in 2 patients (2%) and left atrial flutter in 6 patients (7%). CONCLUSIONS: Epicardial ablation with bipolar radiofrequency grants acute transmurality. A simplified lesion set proved highly effective in eliminating atrial fibrillation at 1-year follow-up. Our data suggest that addition of a lesion to the mitral annulus is advisable to prevent left atrial flutter.

Regional left atrial interstitial remodeling in patients with chronic atrial fibrillation undergoing mitral-valve surgery.

Ablation of the left atrial free wall around the pulmonary vein ostia (LAFW) may be effective in the treatment of chronic atrial fibrillation associated with mitral disease (CAF-MVD). Using light and conventional electron microscopy analyses, we wanted to evaluate, in CAF-MVD, the interstitial remodeling in the LAFW as well as in a more remote region, such as the left atrial appendage (LAA). LAFW and LAA samples were obtained from 33 CAF-MVD patients during combined mitral surgery and radiofrequency ablation and from 16 autoptic controls. Interstitial fibrosis (IF) and perivascular fibrosis (PF), capillary densities and the maximal oxygen diffusion distance were morphometrically determined. In CAF-MVD patients, the LAFW, compared with the LAA, showed a higher percentage of IF (7.16+/-3.23% versus 2.51+/-1.40%, respectively), a lower myocardial capillary density per mm(2) (830+/-106 versus 989+/-173) and an increased oxygen maximal diffusion distance (19.70+/-1.27 microm versus 18.13+/-1.58 microm). All these values were also significantly different than controls. No differences were found in evaluating PF. At variance with the LAA, in CAF-MVD patients, the LAFW around the pulmonary vein ostia is a region characterized by a marked interstitial remodeling such that it may be morphologically indicated as an appropriate target for ablation treatment aimed at sinus rhythm restoration.

A tailored anatomical approach to prevent complications during left atrial ablation.

Atrial fibrillation ablation surgery has grown very popular in recent years. Modern techniques involve creation of linear scars on the left atrial wall using different ablation devices. That raises the concern about new major surgical complications that can be caused by the ablation procedure. Postablation coronary obstruction and esophageal injury have been described. We report our present strategy for left atrial ablation in which the lesion set is tailored to the specific coronary anatomy. Safeguards to prevent esophageal and bronchial injury are also outlined.

Surgical ablation of atrial fibrillation using the epicardial radiofrequency approach: mid-term results and risk analysis.

BACKGROUND: The minor technical and time requirements with respect to the maze operation combined with a comparable efficacy has led to an increasing popularity of left atrial approaches to treat atrial fibrillation. We report our experience with a left atrial procedure based on extensive use of epicardial radiofrequency ablation in an effort to minimize cardiac arrest time. METHODS: A total of 132 consecutive patients with atrial fibrillation (121 chronic, 11 paroxysmal) undergoing open heart surgery had combined intraoperative ablation. An original set of left atrial lesions was performed using a radiofrequency linear catheter. Most of the ablations were performed epicardially before aortic cross-damping. Patients with contraindications to the epicardial approach had the whole lesion set performed endocardially. RESULTS: The mean cardiac arrest time spent for open heart ablations was significantly shorter (5.2 +/- 0.9 minutes with modem catheters) when the epicardial approach was used (107 of 132 patients, 81%). Hospital mortality was 0.8%. Freedom from atrial fibrillation was 77% 3 years after the operation. Of all the variables analyzed, only age at surgery and early postoperative arrhythmias increased the risk of recurrent atrial fibrillation. Overall 3-year survival was 94%. The 3-year actuarial freedom from stroke was 98%. No patient required implantation of a permanent pacemaker. Atrial contractility was recovered in all patients with stable sinus rhythm. CONCLUSIONS: Left atrial radiofrequency ablation allows recovery of sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who undergo open heart surgery. The epicardial radiofrequency approach is a safe and effective means to cure atrial fibrillation with negligible technical and time requirements.

[Concomitant treatment of atrial fibrillation in open-heart surgery patients: late rhythm and functional results]. / Trattamento combinato della fibrillazione atriale in pazienti candidati ad intervento chirurgico a cuore aperto: risultati clinici e funzionali a distanza.

BACKGROUND: In recent years left atrial approaches have become popular because of technical simplicity, reproducibility and minor surgical trauma compared to the standard maze procedure. We analysed mid-term results of intraoperative left radiofrequency ablation of atrial fibrillation. METHODS: From February 1998 to August 2002, 206 patients (mean age 59.1 +/- 10.2 years) scheduled for open-heart surgery underwent combined treatment of atrial fibrillation at our Institution. In 163 patients (79.1%) a standard left epicardial approach was performed while 43 patients (20.9%) needed a totally endocardial approach. RESULTS: All patients but 3 underwent mitral valve surgery (104 repair and 99 replacement). Hospital mortality was 1.9%. Actuarial freedom from atrial fibrillation was 78% at 2 years and 74% at 4 years. At 4 years survival was 94% and freedom from neurological events was 98%. All patients with stable sinus rhythm 3 months after surgery recovered biatrial contractility. CONCLUSIONS: Left radiofrequency ablation of atrial fibrillation is effective in restoring sinus rhythm and normal atrial function. Combined atrial fibrillation treatment should be considered in all patients undergoing open-heart surgery.

Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study.

To evaluate the clinical results of aortic valve replacement performed with a miniaturized closed circuit extracorporeal circulation (MECC) system and to compare it to standard cardiopulmonary bypass (CPB). One hundred and twenty consecutive patients undergoing isolated aortic valve replacement were randomly assigned to either a miniaturized closed circuit CPB with the maquet-cardiopulmonary MECC System (study group, n=60) or to a standard CPB (control group, n=60). Demographic characteristic and operative data were similar in the two groups. No hospital death occurred in either group and no difference in intensive care unit (ICU) stay and in-hospital stay was observed. Patients in the study group showed lower chest tube drainage (212+/-62 ml vs. 420+/-219 ml, P<0.05) and lower need for blood products (6.1% vs. 40.4%, P<0.05) than patients in the control group. Platelet count at ICU arrival was significantly higher in the study group (139+/-40 x 10(9)/l vs. 164+/-75 x 10(9)/l, P=0.05). Peak postoperative troponin I release was significantly lower in the MECC group (3.81+/-2.7 ng/dl vs. 6.6+/-6.8 ng/dl, P<0.05). In this randomized study the MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage as compared to standard CPB.

Complete right atrial ablation with bipolar radiofrequency.

PURPOSE: Although it is deemed important, right atrial ablation is not considered feasible with bipolar radiofrequency alone. Normally, unipolar devices are used to complete the tricuspid connecting lines. We describe a simple technique to achieve a complete maze-like set of right ablations using a standard bipolar radiofrequency device. DESCRIPTION: Thirty-four patients underwent concomitant ablation with a right set of lines performed using bipolar radiofrequency only. The epicardium adjacent to the right atriotomy was entered and after separating the sulcus fat from the atrial wall, the deepest portion of the atrioventricular groove was developed bluntly with the scissors down to the tricuspid annulus. The tricuspid connecting lines were then performed with bipolar radiofrequency in an endo-epicardial fashion. EVALUATION: No ablation-related complications occurred. No patient died. Three patients required pacemaker implantation. At a mean follow-up of 8 +/- 5, 85% of the patients were free from arrhythmias. At 6 months 20 of 24 patients (83%) were in stable sinus rhythm. CONCLUSIONS: All the maze III right atrial ablations can be performed using a bipolar radiofrequency device alone. The procedure is safe and easily reproducible on a regular basis.

Heme oxygenase-1 expression in the left atrial myocardium of patients with chronic atrial fibrillation related to mitral valve disease: its regional relationship with structural remodeling.

Atrial fibrillation becomes a self-perpetuating arrhythmia as a consequence of electrophysiologic and structural remodeling involving the atrium. Oxidative stress may be a link between this rhythm disturbance and electrophysiologic remodeling. The aim of this study was to evaluate whether the heme oxygenase-1 (HO-1) marker of oxidative stress was more expressed in left atrial sites with stronger structural remodeling in patients affected by chronic atrial fibrillation (CAF) and mitral valve disease (MD). Myocardial samples were taken from the left atrial posterior wall (LAPW) and left atrial appendage (LAA) of 24 patients with CAF-MD in addition to 10 autopsy controls. The levels of HO-1 messenger RNA (mRNA) and HO-1 protein in each pathologic LAPW and LAA were quantified using reverse transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay. Furthermore, light microscopy was used to morphometrically evaluate the differential myocyte and interstitial changes in the same CAF-MD LAPW and LAA samples. In controls, HO-1 protein was quantified using enzyme-linked immunosorbent assay. Unlike controls, patients with CAF-MD had higher levels of HO-1 mRNA and its protein product, expressed as LAPW/LAA ratios, in the LAPW (2.18 +/- 1.18, P < .0001, and 1.55 +/- 0.67, P < .005), and their LAPW also showed greater histologic changes in myocytolytic myocytes (15.1% +/- 3.1% versus 6.9% +/- 3.3%, P < .0001), interstitial fibrosis (8.2% +/- 2.2% versus 2.8% +/- 1.2%, P < .0001), and capillary density (816 +/- 120 number/mm(2) versus 1114 +/- 188 number/mm(2); P < .05). In addition, markers of oxidative stress were immunohistochemically studied with antinitrotyrosine and anti-iNOS antibodies. In patients with CAF-MD, the inducible enzyme HO-1 is more expressed in the left atrial areas that show greater structural remodeling. This finding strongly suggests a pathogenetic relationship between oxidative stress and the degree of histologic change.

Cardiopulmonary bypass strategy during concomitant surgical treatment of mitral valve disease and atrial fibrillation.

In recent years, the popularity of simplified intraoperative ablation approaches to treat atrial fibrillation (AF) has been progressively increasing. Our group has described a left atrial procedure based on epicardial radio frequency ablation on cardiopulmonary bypass (CPB). We report our CPB and myocardial protection strategy in 157 patients who underwent AF ablation combined with open-heart surgery from February 1998 to February 2002. Since epicardial ablations are performed on CPB on the beating heart, the CPB strategy is crucial. Total normothermic CPB allows a safe dissection around the pulmonary veins on the decompressed heart; after the ablating catheter has been positioned, an adequate filling of the left atrium favours a uniform contact with the atrial wall. After crossclamping, low-flow retrograde cardioplegia delivery is administered while ablating endocardially to protect the main coronary arteries in the atrio-ventricular groove from radio frequency-related trauma. All patients were successfully weaned from CPB. Sinus rhythm was restored in 152 of 157 (96.8%) patients immediately after surgery. No procedure-related complications were recorded. Epicardial ablations allowed us to reduce significantly the aortic crossclamping time required for ablations. The conduct of CPB and myocardial protection play a central role in the surgical strategy by improving intraoperative feasibility and effectiveness of radio frequency ablation and preventing some of the potential postoperative complications related to the procedure.